By: Dianne Rudolph, DNP, GNP-BC, CWOCN
What are some ways to achieve insurance coverage for fistula pouches or to use ostomy supplies for a fistula? We often run into the issue of supplies not being covered for Medicare or Medicaid patients.
Unfortunately, coverage is inadequate. CMS (Centers for Medicare & Medicaid Services) coverage for fistulas is limited for fistulas caused by or resulting from a surgical procedure, and even then, it may be difficult to get reimbursed. Spontaneous fistulas (15% to 25%) are generally not covered. The Wound, Ostomy and Continence Society is working on trying to effect a change in coverage. Some insurance companies may be more amenable to reimbursement, and it may require a case-by-case application or appeal. For patients being discharged home, it may be possible to secure a short-term supply of 10 to 14 days. The cost for the pouches may run $255 and up for a box of 10.